EARN This course was written for dentists, 3 CE dental hygienists, CREDITS and dental assistants.

© Santos06 | Dreamstime.com Digit-sucking: Etiology, clinical implications, and treatment options

A peer-reviewed article by Alyssa Stiles, BS, RDH, LMT, COM

PUBLICATION DATE: FEBRUARY 2021

EXPIRATION DATE: JANUARY 2024

SUPPLEMENT TO ENDEAVOR PUBLICATIONS EARN 3 CE CREDITS

This continuing education (CE) activity was developed by Endeavor Business Media with no commercial support. This course was written for dentists, dental hygienists, and dental assistants, from novice to skilled. Educational methods: This course is a self-instructional journal and web activity. Provider disclosure: Endeavor Business Media neither has a leadership position nor a commercial interest in any products or services discussed or shared in this educational activity. No manufacturer or third party had any input in the development of the course content. Requirements for successful completion: To obtain three (3) CE credits for this educational activity, you must pay the required fee, review the material, complete the course evaluation, and obtain Digit-sucking: Etiology, an exam score of 70% or higher. CE planner disclosure: Laura Winfield, Endeavor Business Media dental group CE coordinator, neither has a leadership nor clinical implications, and commercial interest with the products or services discussed in this educational activity. Ms. Winfield can be reached at lwinfield@ endeavorb2b.com. treatment options Educational disclaimer: Completing a single continuing education course does not provide enough information to result in the participant being an expert in the field related to the course Educational objectives topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and • Recognize the signs of digit-sucking habits and explain the poten- expertise. tial ramifications Image authenticity statement: The images in this educational activity have not been altered. • Identify possible causes Scientific integrity statement: Information shared in this CE • Determine when to seek treatment course is developed from clinical research and represents the most current information available from evidence-based . • Provide treatment options, referrals, and other resources Known benefits and limitations of the data: The information presented in this educational activity is derived from the data and information contained in the reference section. Abstract Registration: The cost of this CE course is $59 for three (3) Nonnutritive sucking is a normal reflex in infants up to six months of CE credits. Cancellation and refund policy: Any participant who is not age. While most children grow out of this habit, many do not. There are 100% satisfied with this course can request a full refund by several different theories as to why a child may continue the habit. Clini- contacting Endeavor Business Media in writing. Provider information: cal implications include the development or relapse of Dental Board of California: Provider RP5933. Course registration and bony structural changes, speech and articulation issues, chewing number CA code: 03-5933-20010. Expires 7/31/2022. “This course meets the Dental Board of California’s requirements for and swallowing problems, airway and breathing difficulty, and more. three (3) units of continuing education.” The severity of this habit and the corresponding signs are dependent on many factors, including frequency, intensity, duration, and the num- Endeavor Business Media is a nationally approved PACE program ber and position of digits involved. There are several treatment options provider for FAGD/MAGD credit. Approval does not imply acceptance available, which will be discussed in this course. It is important for the by any regulatory authority or AGD dental care provider to be able to identify clinical signs of sucking habits, endorsement. 11/1/2019 to 10/31/2022. determine if and when treatment is necessary, and provide the patient Provider ID# 320452 AGD code: 430 and/or guardian with treatment options, referrals, and other resources. This course will provide the dental care provider with the confidence and knowledge to adequately manage these patients.

Endeavor Business Media is designated as an approved Provider by the American Academy of Dental Hygiene, Inc. #AADHPNW (January 1, 2021-December 31, 2022). Approval does not imply acceptance by a state or provincial Board of Dentistry. Licensee should maintain this document in the event of an audit.

Endeavor Business Media is an ADA CERP–recognized provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of dental continuing education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at ada.org/goto/cerp.

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Etiology of sucking habits digit-sucking. This includes, but is not mimicking a sibling. While there may be Sucking is considered a normal behavior limited to, the psychoanalytical theory, a genetic predisposition to digit-sucking in infants and an important part of human the oral drive theory, the sensory depriva- behaviors, learned behavior may account development. There are two basic types of tion theory, the learning theory, and the for some of the incidences of more than sucking: nutritive and nonnutritive.1 During rooting and sucking reflex theories. Each one individual with a digit-sucking habit nutritive sucking, an infant receives nourish- of these theories, as well as a few other in a family unit.6 ment through a breast or bottle. Nonnutri- hypotheses, will be covered briefly here. tive sucking habits provide no nourishment ROOTING AND SUCKING REFLEX THEORIES and are often associated with finger(s) or a PSYCHOANALYTICAL THEORY Rooting and sucking are infantile reflexes pacifier. Nonnutritive sucking of the fingers In the early 20th century, psychologist Sig- seen from birth, and both of these reflexes is also referred to as “digit-sucking.” Digit- mund Freud established a theory describing are important for feeding. The rooting sucking is considered a habit if it is a pro- digit-sucking as an autoerotic and pleasure- and sucking reflex theories suggest that longed or repetitive behavior.2 seeking behavior, with an underlying cause an infant’s primitive reflexes are respon- Both nonnutritive and nutritive suck- related to psychopathology and problems sible sucking behaviors, and a failure of ing are rhythmical and involve two basic with emotional development.2 He proposed reflex integration results in an abnormal, components: suction and expression. Suc- that sucking behaviors stimulate the eroge- prolonged habit. tion involves the negative pressure created nous zone of the mouth. Erogenous zones are The rooting reflex occurs when a child by the lip seal and velopharyngeal closure bodily areas with concentrated nerve end- turns his or her head toward a stimulus. as the is lowered. Expression ings and are highly sensitive. He suggested The rooting reflex is active until about involves the upward compressive move- that sucking occurs because of an infant’s three to six months of age. The sucking ment of the tongue.3 need for satisfaction rather than the need for reflex occurs when the palate is stimu- Though nonnutritive sucking provides nutrition.2,5 While psychoanalytical theory lated. The sucking reflex is active until no nourishment, there are many known was once very influential, its reputation has six to 12 months of age, but a child can benefits. Nonnutritive sucking can pro- declined in recent decades. continue to suckle and suck liquid from mote self-regulation and mouth explora- the breast and bottle as needed.7 Around tion. It can also help with the coordination ORAL DRIVE THEORY five to six months of age, children begin of sucking and swallowing patterns and This theory supports the Freudian belief discriminative mouthing, which will pro- has been used strategically to facilitate that sucking increases the erotogenesis of mote a child’s ability to eat solid foods. transitioning from tube to oral feeding the mouth, but it further suggests that the Around this age, because complementary in preterm infants.4 strength of an individual’s drive to suck foods are introduced, infants are no longer Sucking can sometimes be seen on is determined by how long he or she is fed dependent solely on sucking for nutrition. imaging in utero, with the fetus sucking through nutritive sucking. According to finger(s) and swallowing amniotic fluid.2 this theory, the oral drive is strengthened NEUROPHYSIOLOGICAL EFFECTS AND THE Internationally, the incidence of digit-suck- through prolonged nursing, rather than BRAIN’S REWARD SYSTEM ing in early life is reported to be anywhere the frustration of weaning.5 Another hypothesis is that sucking results between 34% to 90%, and many children in a release of “happy” hormones, so chil- stop nonnutritive sucking habits as they SENSORY DEPRIVATION THEORY dren suck because it feels good. Research age.2 The average age of habit cessation According to this theory, repetitive digit- has shown that digit-sucking produces is just less than four years old.2 Still, some sucking may induce sensory deprivation.2 this positive neurological response at the children fail to grow out of the habit and It is thought that the frequent and monoto- incisive papilla, an area of highly con- continue it throughout adulthood. Accord- nous stimulation may lead to the reduction centrated nasopalatine nerve receptors, ing to both the American Association of of sensory receptors in the mouth, and this which are linked to the locus coeruleus. Orthodontists and the American Dental deprives an individual of normal sensory The locus coeruleus is an area of the brain Association, if a child does not quit a digit- input. This hypoarousal may cause a child to associated with the neurotransmitters sucking habit on his or her own by age four, suck even more to achieve the same results. serotonin, norepinephrine, acetylcholine, the parents should actively discourage the and dopamine.8 Additional research in habit.2 Digit-sucking is considered chronic LEARNING THEORY infant pain management has validated if it occurs in at least two environments The learning theory holds that digit- that serotonin production increases as a (e.g., home, school, or another location) sucking is not simply an innate behav- result of nonnutritive sucking.9 Some have after the child is five years of age.2 ior but rather a learned behavior. One suggested that the levels of beta endor- To properly address a digit-sucking way that children learn is through “mir- phins can also be modulated through habit, it is important to understand the roring”: observing and imitating others, nonnutritive sucking, but evidence to possible underlying causes. To date, their actions, and the resultant rewards. substantiate this claim is lacking. several theories and hypotheses have For example, according to this theory, Because sucking feels good, it incen- been proposed regarding the etiology of sucking habits could arise from a child tivizes the brain’s reward system. There

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are three basic divisible psychological basis of this hypothesis is that digit-suck- objects and/or other concomitant habits, components of a reward system: liking, ing can seal the lips, pulling the tongue such as hair-twirling or blanket-sucking. wanting, and learning. “Liking” refers to and down and forward to promote There have been many attempts to classify the hedonic impact, “wanting” refers to nasal breathing, as in the head-tilt/chin- digit-sucking, including Subtelny (1973), incentive salience, and “learning” refers to lift and jaw-thrust maneuvers used with Cook (1995), and Johnson (1993), based predictive associations and cognitions.10 CPR. Fingers can also be used to prop the on various factors, such as the position Digit-sucking is analgesic in nature and mouth open at night to facilitate mouth of the digit in the mouth.19 can be used to self-soothe and cope with breathing.17 Research reveals that a lower pain, fear, anxiety, or other psychological respiratory rate and an increase in oxy- Effects of digit-sucking disturbances. gen levels often occur during nonnutri- MALOCCLUSIONS AND ROOT RESORPTION tive sucking.12 Teeth are subject to both intrinsic (e.g., DIGIT-SUCKING AS A CONSEQUENCE OF lips, cheek, and tongue) and extrinsic (e.g., DIGIT-SUCKING RELATED TO HUNGER and/or digits) forces, and six Another suggested cause of thumb suck- Some have suggested that infants exhibit hours of force applied each day is needed ing is ankyloglossia. At rest, the tongue nonnutritive sucking behaviors due to a in order to elicit tooth movement.2 Digit- should be in a palatal position with the lack of satiety after a feed. sucking can alter the balance of forces on tip touching the incisive papilla. It has the teeth and has the potential to cause been suggested that a tongue that is Assessing severity tooth movement.2 One of the most com- restricted in its movement (i.e., anky- Severity of a digit-sucking habit is deter- mon malocclusions seen with digit-suck- loglossia) cannot stimulate the palate, mined by a combination of several factors, ing is the anterior open bite.20 An anterior and a child may use his or her digits for including the frequency, intensity, dura- open bite can be symmetrical or asym- self-stimulation.11 tion, as well as the number and position metrical, depending on the position of of digits involved. Frequency is defined as the digits during the habit.21 An anterior DIGIT-SUCKING TO AID IN SLEEP how often the habit occurs during a given open bite is one of the most difficult mal- Serotonin released during sucking has period. Intensity is defined as the force of occlusions to manage orthodontically, been associated with happiness and sucking bursts in a given period. Duration and posttreatment orthodontic relapse vast physiological functions and behav- can be defined as the length of time that is common.22 iors, including eating, sleeping, circa- the sucking continues. Other common malocclusions seen dian rhythmicity, and neuroendocrine Not all digit-sucking habits involve the in digit-sucking individuals include the function.12 The tonic stimulation of the thumb. One or more digits can be involved. posterior crossbite, overjet, flaring of the serotonergic system during wakeful peri- Children will often develop an affinity for maxillary incisors, and in more severe ods has been associated with the gen- a particular hand or finger(s).18 Some digit- cases, the lingual retrusion of the man- eration of “sleep pressure,” which, along sucking habits also involve transitional dibular anterior incisors.20,21 Digit-sucking with the circadian clock, is essential for good, restorative sleep.13,14 Serotonin is also the precursor to the hormone melato- nin, which is important in the regulation of the sleep-wake cycle.15 Interestingly, nonnutritive sucking is common during periods of fatigue and at bedtime, indicat- ing that perhaps finger-sucking is used to build up sleep pressure. Nighttime digit-sucking can ease a child to sleep. Research has shown that infants who engage in digit-sucking expe- rience fewer night wakings, less sleep dur- ing the day, and longer stretches of sleep at night.16 It is rumored that digit-suck- ing can stimulate deeper stages of sleep, although no research has been done on this hypothesis to date.

DIGIT-SUCKING TO PROTECT THE AIRWAY Another hypothesis is that digit-sucking FIGURE 1: The pressure from the thumb, lips, and tongue can contribute to changes in dentofacial can be used to protect the airway. The development.1

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buccinator, superior pharyngeal constric- tor, and pterygomandibular raphe.1 Hyper- activity of the buccinator muscles can put excessive, unbalanced pressure on teeth and the alveolar bone, which can result in narrow arches and malocclusions.30 Electromyography (EMG) assessments of digit-sucking revealed that lip muscles and the mentalis are also very active dur- ing nonnutritive sucking activities.31,32 With digit-sucking, the lower lip can become hyperactive, and the upper lip becomes shortened and hypotonic, con- tributing to lip incompetence.8 Mean- while, the finger(s) displaces the tongue FIGURE 2: During digit sucking, the tongue is depressed into the mandible. From this low position, the in a downward position, away from the 28 pressure from the tongue cannot counterbalance the pressure exerted by the lips and cheek. maxillary arch.25 With the tongue rest- ing in a low and forward position, digit- has also been frequently associated with orthodontic expansion or surgical inter- sucking also promotes tongue-thrust angle class II malocclusions.20 Increas- vention to correct. swallowing. A tongue-thrust swallow is ing the frequency, intensity, and dura- characterized by dentalized tongue move- tion of the habit correlates proportionally ORAL AND FACIAL MUSCLE DYSFUNCTION ment during the swallow, in an anterior with an increase in the risk of developing Digit-sucking involves the unfavorable or lateral direction. a .2 use of the oral and facial muscles. This is Retraining the tongue to rest in the Orthodontists experience some other known as an orofacial myofunctional dis- proper palatal position after digit-suck- unique challenges in treating children order. An orofacial myofunctional disorder ing has been eliminated is imperative for with nonnutritive sucking habits. For is defined as the “abnormal resting labial- long-term stability of the orthodontic example, atypical root resorption of pri- lingual posture of the orofacial muscula- treatment and the prevention of many mary and permanent central incisors has ture, atypical chewing and swallowing other problems.26,27 Orofacial myo- been noted in thumb-sucking patients.23 patterns, dental malocclusions, blocked functional therapy can be used to help This is a factor the orthodontist should nasal airways, and speech problems.”29 patients to achieve palatal tongue rest consider during treatment planning. The main structures used for sucking posture and lip closure. It can also be are the masseter, orbicularis oris, mentalis, used to correct tongue functioning ALTERATIONS IN OROFACIAL GROWTH AND DEVELOPMENT Tooth positioning is not the only orth- odontic concern for individuals with digit- sucking habits. The forces created as a result of a digit-sucking habit can alter the general trajectory of orofacial growth and development in both the horizontal and vertical planes. Children with pro- longed digit-sucking habits have a propen- sity toward undesirable skeletal changes and a downward (vertical) facial growth pattern, a deficient midfacial profile, and a narrow, v-shaped maxillary arch.24-26 Nonnutritive sucking has been associ- ated with a decrease in maxillary intra- arch distance, which corresponds with a decrease in nasopharyngeal airway capac- ity.27 In a narrow maxillary arch, there may not be enough room to accommo- date a proper palatal rest position for the FIGURE 3: The main structures involved in sucking and swallowing are the: 1) masseter, 2) orbicularis tongue. A narrow upper jaw may require oris, 3) mentalis, 4) buccinator, 5) superior pharyngeal constrictor, and 6) pterygomandibular raphe.1

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during chewing and swallowing as well therapy, reward therapy, punishment ther- PSYCHOLOGICAL THERAPY as lip incompetence.33 apy, appliance therapy, and orofacial myo- Creating distractions and keeping the Digit-sucking children have three functional therapy. hands busy could be considered psycho- times the risk of developing a speech logical therapy. Professional psychologi- sound disorder.34 Articulators used in PREVENTION cal counseling may also be employed as speech sound production include the Treatment for digit-sucking habits in needed in patients who are unwilling pharynx, velum/soft palate, hard palate, infants is mostly preventive in nature. and/or unresponsive to quitting, suck- alveolar ridge, tongue, teeth, and lips. Some parents may choose to substitute ing for attention, or seeking revenge.20 Research has shown that there is a cor- the finger with a pacifier. By providing Current psychotherapeutic techniques relation between “s” sound distortions a child with a pacifier, the parent may to address digit-sucking may include, and increased overjet.35 Other research feel that they have more control over but are not limited to, cognitive behav- reveals an association between anterior weaning their child from the habit. The ioral therapy, motivational interviewing, open bites and lisps.35 Orthodontic habit American Academy of Pediatrics and and insight therapy. Psychiatric interven- appliances used to correct digit-sucking the American Academy of Family Phy- tion or psychotherapy may be especially and/or tongue-thrusting can also interfere sicians both agree that, if a pacifier is important for an individual experienc- with various speech sounds.36 Research on used, children should be weaned from ing bullying, home or family problems infants suggests that limited free tongue it within the second six months of life.41 (e.g., moving, divorce, or death), abuse, movement can negatively impact auditory Around six months of age, the parent or other issues. speech perception.37

2,40 OTHER COMPLICATIONS Figure 4: Current guidelines for digit-sucking Digit-sucking can put a child at AAPD ADA increased risk of developing infections • AAPD supports the • Praise children when they don’t suck their and other conditions of the lips, mouth, individualized approach thumb (e.g., verbal praise, stickers). and fingers. Irritation of the lips, oral for each child in • Find alternative ways of comforting and mucosa, and fingers has been noted. evaluating oral habits. One example is “dishpan finger,” which soothing for children (e.g., stuffed toy). • Where appropriate, the is a form of contact dermatitis related to • Provide reminders or negative reinforcement AAPD encourages treatment irritation from frequent moisture.5 Bony for thumb sucking (e.g., place topical bitter of oral habits to prevent 38 liquids such as Mavala Stop and Thum on the deformities can be noted in the fingers. or intercept possible thumb; put a bandage around the thumb). Studies have shown that digit-sucking malocclusion or skeletal children have a higher chance of devel- dysplasia from occurring. • Involve older children in ways in which oping infections, including parasites they can stop sucking (e.g., have children (e.g., pinworms), compared to nonsuck- help create their own reward system). ing children.39

Habit cessation may be able to introduce age-appro- REMINDER THERAPY Digit-sucking is a complex issue. Cessa- priate items for the infant to chew or For a reminder to be effective, a patient tion is possible, but additional steps may mouth on, instead of suck.7 must be compliant and ready to quit. A be needed to ensure a successful quit Parents may decide to swaddle their reminder is neither a punishment nor attempt, including screening for possible infant as a preventive measure. Swad- reward; it is neutral. Oral deterrent ther- contributors to the habit (e.g., an assess- dling can be calming, promote sleep, and apy, when not used as a punishment, can ment of the airway and restrictive lingual provide nonpharmacologic pain manage- be considered a form of reminder therapy. range of motion evaluation). A negative ment.42 Swaddling should be used in mod- This involves application of a distasteful experience with a quitting attempt can eration, as it poses some risks to infants, substance on the fingers, such as capsa- negatively impact future attempts. including the limitation of natural growth, icin or another chemical. While the American Academy of Pedi- development, and movement. Other common types of reminders atric Dentistry and the American Den- Another way to potentially prevent a are finger bandages, digit tape, or soft tal Association offer some guidelines for digit-sucking habit from occurring in the hand coverings (e.g., gloves or socks). treatment, as shown in figure 4, there is first place is through breastfeeding at will, It is worth noting that there have been no standard treatment for the cessation allowing the child to feed to his or her a few reports of tourniquet syndrome of nonnutritive sucking habits. Cessa- content when he or she shows signs of as a result of reminder bandages being tion methods can be classified into the hunger. Some research has shown that applied too tightly. Caregivers should following general categories: preventive bottle-feeding does not appear to have be mindful of this when applying therapy, psychological therapy, reminder the same effect.42 reminders.43

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REWARD THERAPY OROFACIAL MYOFUNCTIONAL THERAPY 8. Ferrante A, Ferrante A. Finger or thumb sucking. New Reward therapy can be useful for an indi- Orofacial myofunctional therapists interpretations and therapeutic implications. Minerva 2015;67(4):285-297. vidual who is ready to quit a habit and offer positive, appliance-free habit ces- Pediatr. simply needs a good reason. This involves sation programs that tout high success 9. Gibbins S, Stevens B. Mechanisms of sucrose and nonnutritive sucking in procedural pain management offering prizes to children when they do rates.46,47 Orofacial myofunctional thera- in infants. Pain Res Manage. 2001;6(1):21-28. not suck. Contingency contracting (also pists educate, empower children to take doi:10.1155/2001/376819 known as bribing) can also be a form of control over their own habits, encourage 10. Arias-Carrión O, Stamelou M, Murillo-Rodríguez reward therapy. family involvement in the process, and E, et al. Dopaminergic reward system: a short provide support and accountability. Oro- integrative review. Int Arch Med. 2010;3:24. PUNISHMENT facial myofunctional therapists combine doi:10.1186/1755-7682-3-24 Parents are often unaware that when it aspects of other therapeutic techniques, 11. Van Norman RA. Digit-sucking: a review of the comes to digit-sucking, punishment is such as reminders, rewards, and distrac- literature. Int J Orofacial Myology. 1997;23:14-34. largely ineffective. Common forms of pun- tions. Once the cessation of digit-suck- 12. Harding C. An evaluation of the benefits of ishment include taking away a comfort or ing has been achieved, a child may be a nonnutritive sucking for premature infants transition object or nagging. Negativity candidate for a full orofacial myofunc- as described in the literature. Arch Dis from caregivers can have the opposite of tional therapy program to correct tongue Child. 2009;94(8):636-640. doi:10.1136/ the desired effect, as it can cause a child rest posture, lip incompetence, as well adc.2008.144204 to hide their habit or suck even more. It is as maladaptive chewing and swallow- 13. Oikonomou G, Altermatt M, Zhang R-W, et al. The recommended that caregivers use a kinder ing patterns. serotonergic raphe promote sleep in zebrafish and gentler approach.20 and mice. Neuron. 2019;103(4):686-701.e8. Conclusion doi:10.1016/j.neuron.2019.05.038 MECHANICAL RESTRAINTS There are many hypotheses regarding the 14. California Institute of Technology. Settling the debate Mechanical restraints, such as thumb or etiology of digit-sucking habits. We now on serotonin’s role in sleep: The brain chemical arm guards, physically prevent an individ- know that digit-sucking may be more than is necessary to get enough sleep. ScienceDaily. ual from putting his or her hands in the just a bad habit; it may be a compensatory June 24, 2019. https://www.sciencedaily.com/ mouth. They can be purchased or made strategy related to ankyloglossia or an air- releases/2019/06/190624173822.htm at home. Parents sometimes use elastic way obstruction.26 It is the medical and 15. Frazer A, Hensler JG. Basic Neurochemistry: bandage wraps with popsicle sticks to pre- dental provider’s duty to screen for those Molecular, Cellular and Medical Aspects. 6th ed. Lippincott-Raven; 1999. vent the digit(s) from reaching the mouth. conditions before recommending any form Some “three-alarm systems” have of intervention. An appropriately timed and 16. Butler R, Moore M, Mindell JA. Pacifier use, finger-sucking, and infant sleep. Behav Sleep Med. also been proposed. These systems offer successful quit attempt can redirect orofa- 2016;14(6):615-623. doi:10.1080/15402002.2015. multiple reminders and/or mechanical cial growth and development and prevent 1048451 restraints as a fail-safe. many long-term problems. 17. Moses AJ. Thumb-sucking or thumb-propping? CDS Review. 1987;80(11):40-42. APPLIANCE THERAPY References 18. Hepper PG, Wells DL, Lynch C. Prenatal 1. Turgeon-O’Brien H, Lachapelle D, Gagnon PF, Appliance therapy for digit-sucking thumb sucking is related to postnatal et al. Nutritive and nonnutritive sucking habits: a involves fixed or removable orthodontic handedness. Neuropsychologia. 2004;43(3):313- review. ASDC J Dent Child. 1996;63(5):321-327. appliances designed to prevent an individ- 315. doi:10.1016/j.neuropsychologia.2004.08.009 2. Khayami S, Bennani F, Farella M. Fingers in ual from sucking his or her finger(s). They 19. Johnson ED, Larson BE. Thumb-sucking: mouths: from cause to management. N Z Dent J. may include cribs, spikes, rakes, prongs, classification and treatment. ASDC J Dent Child. 2013;109(2):49-54. or other types of “reminders.” 1993;60(4):392-398. 3. Lau C. Development of suck and swallow Orthodontic appliances have some lim- 20. Radford JR, ed. Oral habits – Part 1: The dental mechanisms in infants. Ann Nutr Metab. itations. First of all, they can be considered effects and management of nutritive and non- 2015;66(05):7-14. doi:10.1159/000381361 punitive. They may be contraindicated nutritive sucking oral habits – Part 2: Beyond 4. McGrath JM, Bodea Braescu AV. State of the in patients with a high dental caries risk nutritive and non-nutritive sucking. Br Dent J. science: feeding readiness in the preterm infant. and/or lack of cooperation.20 They also 2015;218(10):571. doi:10.1038/sj.bdj.2015.399 J Perinat Neonatal Nurs. 2004;18(4):353-368. 21. Kwon O, Haria PJ, Kotecha S. Recognition, have been associated with restrictions doi:10.1097/00005237-200410000-00006 in food choices and an impaired ability to intervention and management of digit-sucking: a 5. Toseska-Spasova N, Dzipunova B, Tosheska- clinical guide for the general dental practitioner. Prim chew and swallow, taste, and process emo- Trajkovska K, et al. Nonnutritive sucking habit— 44 Dent J. 2016;5(4):56-60. tions. Furthermore, fixed or removable thumb-sucking. J Morphol Sci. 2019;2(1):18-23. 22. Tanny L, Huang B, Naung NY, Currie G. Non- orthodontic habit appliances can inhibit 6. Davidson L. Thumb and finger sucking. Pediatr Rev. orthodontic intervention and non-nutritive sucking the growth and development of the dental 2008;29(6):207-208. doi:10.1542/pir.29-6-207 arches.45 Finally, some determined chil- behaviours: a literature review. Kaohsiung J 7. Bahr D. Nobody Ever Told Me (or My Mother) That!: Med Sci. 2018;34(4):215-222. doi:10.1016/j. dren will still indulge in their habit with Everything from Bottles and Breathing to Healthy kjms.2018.01.006 orthodontic appliances in place. Speech Development. Sensory World; 2010.

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23. Mortelliti GM, Needleman HL. Risk factors associated in thumb- and finger-sucking patients. J Dent Res. 41. Sexton S, Natale R. Risks and benefits of with atypical root resorption of the maxillary primary 1960;39:536-553. doi:10.1177/00220345600390 pacifiers. Am Fam Physician. 2009;79(8):681-685. central incisors. Pediatr Dent. 1991;13(5):273-277. 031601 42. Nelson AM. Risks and benefits of swaddling 24. Moore GJ, McNeill RW, D’Anna JA. The effects 33. Hockenbury DK. Can we ‘grow lips’ in therapy? The healthy infants. MCN Am J Matern Child of digit-sucking on facial growth. J Am Dent efficacy of lip stretching and strengthening exercises Nurs. 2017;42(4):216-225. doi:10.1097/ Assoc. 1972;84(3):592–599. doi:10.14219/jada. in patients with lip incompetence. J Dent Oral Health. nmc.0000000000000344 archive.1972.0096 Nov. 2, 2018. 43. McGrath R, McCarron L, Cahill K, et al. P107 thumb 25. Cozza P, Baccetti T, Franchi L, et al. Sucking 34. Barbosa C, Vasquez S, Parada MA, et al. The auto-amputation following tourniquet syndrome. Arch habits and facial hyperdivergency as risk factors relationship of bottle feeding and other sucking Dis Child. 2019;104(Suppl 3):A199. doi:10.1136/ for anterior open bite in the mixed dentition. Am J behaviors with speech disorder in Patagonian archdischild-2019-epa.462 Orthod Dentofacial Orthop. 2005;128(4):517-519. preschoolers. BMC Pediatr. 2009;9:66. doi:https:// 44. Carter LA, Geldenhuys M, Moynihan PJ, et al. doi:10.1016/j.ajodo.2005.04.032 doi.org/10.1186/1471-2431-9-66 The impact of orthodontic appliances on eating— 26. Donofrio L. Oral dysfunction as a cause of 35. Borrie FRP, Bearn DR, Innes NPT, Iheozor-Ejiofor Z. young people’s views and experiences. J Orthod. malocclusion. Orthodontics Craniofac Res. Interventions for the cessation of pacifier or digit- 2015;42(2):114-122. doi:10.1179/146531331 2019;22(S1):43-48. doi:10.1111/ocr.12277 sucking habits in children. Cochrane Database Syst 4y.0000000128 27. Agarwal SS, Nehra K, Sharma M, et al. Association Rev. 2015;3: CD008694. doi:10.1002/14651858. 45. Klein ET. The thumb-sucking habit: meaningful between breastfeeding duration, non-nutritive cd008694 or empty? Am J Orthod. 1971;59(3):283-289. sucking habits and dimensions 36. Chen J, Wan J, You L. Speech and orthodontic doi:10.1016/0002-9416(71)90101-1 in deciduous dentition: a cross-sectional appliances: a systematic literature review. Eur J 46. Huang B, Lejarraga C, Franco CS, et al. Influence of study. Prog Orthod. 2014;15(1):59. doi:10.1186/ Orthod. 2018;40(1):29-36. doi:10.1093/ejo/cjx023 non-orthodontic intervention on digit-sucking and s40510-014-0059-4 37. Bruderer AG, Danielson DK, Kandhadai P, consequent anterior open bite: a preliminary study. Int 28. Van Norman RA. Helping the Thumb Sucking Child. Werker JF. Sensorimotor influences on speech Dent J. 2015;65(5):235-241. doi:10.1111/idj.12178 Avery; 1999: 33. perception in infancy. Proc Natl Acad Sci USA. 47. Green SE. Confirmational study: a positive-based 29. Billings M, Gatto K, D’Onofrio L, et al. Orofacial 2015;112(44):13531-13536. doi:10.1073/ thumb and finger sucking elimination program. Int J myofunctional disorders. OMD overview. pnas.1508631112 Orofacial Myology. 2010;36:44-59. October 2018. http://iaom.com/wp-content/ 38. Srinivasan J, Hutchinson JW, Burke FD. Finger uploads/2018/10/OMD-Overview-IAOM.pdf sucking digital deformities. J Hand Surg Eur Vol. ALYSSA STILES, BS, RDH, 30. Rathee M, Jain P. Anatomy, Head and Neck, 2001;26(6):584-588. doi:10.1054/jhsb.2001.0679 LMT, COM, is a registered Buccinator Muscle. StatPearls Publishing; Sep. 22, 39. Idowu OA, Babatunde O, Soniran T, Adediran A. dental hygienist with experience in both general and pediatric 2019. Parasitic infections in finger-sucking school age dental offices. She is a former children. Pediatr Infect Dis J. 2011;30(9):791-792. 31. Sanguida A, Dutta S, Magu S, et al. Ultrasonographic instructor in the University of doi:10.1097/inf.0b013e31821e8449 study of masseter and orbicularis oris muscles after Pittsburgh Dental Hygiene cessation of thumb sucking habit–a pilot study. Sch J 40. American Academy of Pediatric Dentistry. Policy Department. Alyssa is a certified Dent Sci. 2017;4(6):254-258. Statement on Oral Habits. Revised 2003. https:// orofacial myologist and owner of 32. Baril C, Moyers RE. An electromyographic analysis www.aapd.org/assets/news/upload/2003/270.pdf Pittsburgh Orofacial Myofunctional Therapy, LLC, where she helps children overcome oral habits. of the temporalis muscles and certain facial muscles

Notes

DentalAcademyofCE.com 47 ONLINE COMPLETION QUICK ACCESS code 20010 Use this page to review questions and answers. Visit dentalacademyofce.com and sign in. If you have not previously purchased the course, select it from the Online Courses listing and complete your online purchase. Once purchased, the exam will be added to your Archives page, where a Take Exam link will be provided. Click on the Take Exam link, complete all the program questions, and submit your answers. An immediate grade report will be provided. Upon receiving a grade of 70% or higher, your verification form will be provided immediately for viewing and printing. Verification forms can be viewed and printed at any time in the future by visiting the site and returning to your Archives page.

1. Which of the following is true about 6. Which of the following theories states 11. Which of the following theories sucking in infants? that digit-sucking leads to the reduction associates digit-sucking with natural A. Sucking is considered a normal behavior. of sensory receptors in the mouth, thus infantile reflexes of rooting and sucking? B. There are two basic types of sucking. reducing an individual’s normal sensory A. Learning theory input? C. Both A and B B. Combination of psychoanalytic A. Psychoanalytical theory D. Neither A nor B and learning theories B. Oral drive theory C. Rooting and sucking reflex theories 2. Nonnutritive sucking can help with: C. Sensory deprivation theory D. Sensory deprivation theory A. Exploration D. Oral gratification theory B. Self-regulation 12. The ___ reflex is active until about 7. Which of the following theories was first 3-6 months of age and involves a child C. Transitioning from tube proposed by Sigmund Freud and states turning his or her head to the side of the feeding to oral feeding that digit-sucking is an autoerotic and face that is touched. D. All of the above pleasure-seeking behavior? A. Rooting 3. Sucking behaviors are often first A. Psychoanalytical theory B. Sucking observed in utero, and the average age of B. Oral drive theory C. Moro digit-sucking cessation is: C. Sensory deprivation theory D. Walking/stepping A. In the first six months D. Oral gratification theory B. In the first year 13. The ___ reflex is active until about 6 to 8. Which class of malocclusion has been 12 months of age and involves a child C. Just before age 4 frequently associated with digit-sucking? sucking anything that touches the roof of D. By age 15 A. Class I the mouth. 4. According to both the American B. Class II A. Rooting Association of Orthodontists and the C. Class III B. Sucking American Dental Association, if a child D. None of the above C. Moro does not quit a digit-sucking habit on D. Walking/stepping his or her own by age ___, the parents 9. Which of the following theories states should actively discourage the habit. strength of an individual’s drive to suck 14. Research has shown that digit-sucking A. 6 months is determined by how long he or she is produces this neurotransmitter. B. 1 year fed through nutritive sucking and not the A. Serotonin frustration of weaning? C. 2 years B. Cortisol A. Psychoanalytical theory D. 4 years C. Both A and B B. Oral drive theory D. Neither A nor B 5. Digit-sucking is considered chronic if it C. Sensory deprivation theory occurs in at least ___ environment(s) D. Oral gratification theory 15. Which of the following is not part of the (e.g., home, school, or another location) brain’s reward system? after five years of age: 10. Which of the following theories states A. Liking A. One that digit-sucking is not innate and must B. Wanting be learned? B. Two C. Avoiding A. Learning theory C. Three D. Yearning D. Four B. Combination of psychoanalytic and learning theories C. Rooting and sucking reflex theories D. Sensory deprivation theory

48 DentalAcademyofCE.com ONLINE COMPLETION QUICK ACCESS code 20010 Use this page to review questions and answers. Visit dentalacademyofce.com and sign in. If you have not previously purchased the course, select it from the Online Courses listing and complete your online purchase. Once purchased, the exam will be added to your Archives page, where a Take Exam link will be provided. Click on the Take Exam link, complete all the program questions, and submit your answers. An immediate grade report will be provided. Upon receiving a grade of 70% or higher, your verification form will be provided immediately for viewing and printing. Verification forms can be viewed and printed at any time in the future by visiting the site and returning to your Archives page.

QUESTIONS QUESTIONS

16. This condition involves limited range 21. Which of the following is true about an 27. The American Academy of Pediatrics of motion of the tongue. It has been anterior open bite (AOB)? and the American Academy of Family proposed that with this condition, the A. It can be symmetrical or asymmetrical. Physicians both agree that, if a pacifier is tongue cannot stimulate the palate, B. It can be difficult to manage used, children should be weaned from it: and a child may use his or her digits for orthodontically. A. In the second 6 months of life self-stimulation. C. Posttreatment orthodontic B. After 1 year A. Macroglossia relapse is common. C. After 2 years B. D. All of the above D. Both advocate actively discouraging C. Lip incompetence pacifier use at any age. D. Ankyloglossia 22. Swaddling, breastfeeding at will, and replacements are considered ___ 28. This type of therapy can help with lip 17. Research has shown that infants who treatments. incompetence: engage in digit-sucking experience which A. Preventive A. Orofacial myofunctional therapy of the following? B. Reward B. Speech therapy A. Fewer night wakings C. Mechanical C. Occupational therapy B. Less sleep during the day D. Appliance D. Physical therapy C. Longer stretches of sleep at night D. All of the above 23. Fixed and removable orthodontic devices 29. Which of the following are types of are a form of ___ therapy. psychological techniques that can be 18. This hormone is the precursor for A. Preventive used to treat digit-sucking? melatonin, which helps to regulate the B. Reward A. Cognitive behavioral therapy sleep-wake cycle. C. Mechanical B. Motivational interviewing A. Cortisol D. Appliance C. Insight therapy B. Dopamine D. All of the above C. Serotonin 24. Prizes given for not sucking are a form of D. Endorphins ___ therapy. 30. Cribs, spikes, rakes, prongs, and other A. Preventive reminders are types of ___ therapy. 19. Which of the following factor(s) B. Reward A. Preventive determines the severity of a sucking C. Mechanical B. Reward habit and correlates proportionally with C. Mechanical an increase in the risk of developing a D. Appliance D. Appliance malocclusion? 25. Arm splints, braces, or other immobilizers A. Frequency are a form of ___ therapy. B. Intensity A. Preventive C. Duration B. Reward D. All of the above C. Mechanical 20. According to the research, ___ hour(s) of D. Appliance force applied each day is needed in order 26. Reminders should be: to elicit tooth movement. A. Rewards A. 1 B. Punishments B. 4 C. Neutral C. 6 D. None of the above D. 18

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Digit-sucking: etiology, clinical implications, and treatment options

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